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Welcome to niboonsh’s page.
Contributor score: 336


Comments ...

 +1  (free120#24)
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xanertel tdaoric nhacbr elpipssu eth orrpesui otryirdahpa lgadsn as ...e...?.wl.l

yng  Yes the superior part supplied by superior thyroid gland which is a branch of external carotid branch. +
llamastep1  No they do not, parathyroids are supplied by the inferior thyroid arteries. https://teachmeanatomy.info/neck/viscera/parathyroid-glands/ +11
suckitnbme  Superior thyroid artery does supply some blood to the parathyroids through anastomoses but the main vascular supply is from the inferior thyroid artery. +

 +2  (nbme18#23)
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cecCrNOint - irtCNssctO eivrclnte

cCtinCEer - CdsapCnE clnteivre )x(enpasd

jmangels  Also, he's an endurance athlete. It would most likely be a physiological adaptation. "Volume overload-induced cardiac hypertrophy is known as eccentric hypertrophy. In endurance training, the volume load is a predominant factor; therefore, the endurance-trained heart develops eccentric hypertrophy" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2300466/ +2
cbreland  Also, the patient has nothing wrong with him, no symptoms, so the other options are a no go +

 +3  (nbme23#35)
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neO fo the esnsitouq ni teh orldwu cecpatir tste 2 yuacatll eouhdtc on .isth

mataoolnvtii wtnnri eiogaenintvi icd:i
  • tnceussab ues ssdrirode
  • roeht esaibhrvo in ietstnap hwo ear tno dyare ot gnahce
inrelis ppc
  • lweakcedngo eesctsainr ot enhagc
  • sdraeds inersecsdacip nwebeet brvaheio dna onlg emrt saglo
  • neaench iottvioamn to hecgna
  • mntoegaljnund
nqTeec hiu AS) OR(
  • skA O-nepneded tienqsuos oe(ragnuec rhtfreu sciisosdun)
  • Give nAimsffaitor
  • lRfeetc nad azireummS ainm opnsit

 +1  (nbme23#34)
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LHht.aTIetM/m0wEE:pILV.dRhbV.heu5./elp/Lt9sdh/umtat


 -4  (nbme23#33)
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.g3e/it/9psvotp.//lcrMnb.P0iClh.sc01:/tih/nwnmc9m6waw


 +3  (nbme20#13)
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nodfu tsih inoen:l /.8c9rt4kptc1au/uparh2/e5y4e.mt0s/0dme/aci/o:mp5o/hr0i/0alc

eHcpyorhptir aymlrunop rspeorothttaoyah AP(HO) si a reyodsmn tezhdreciaacr yb het ridat of p,esstiiiotr lgaidit cilnbgub nad fipuanl yhphrarotta fo eht elgar ij,onst lypseaceli vvliignno eht wleor bilsm. gbnuilbC si azecaiderhtrc yb suloubb maeegentnlr fo remitlan tmssneeg of eht ergifsn adn teso edu to reiroaitpofln fo lusunbgau oneecitcnv t.iusse

rmiyrp...a si a aerr erarihydte oi.ndtnioc

A jtmyroai of esacs 9%)t0&(g; fo oyesarndc HOPA rea scaadsioet itwh ulroynmpa aleainscngim ]6[ ro oncrhic upapsvriteu proyulmna sds.eeais

lPunoramy lcgai,emsainn dninlguic ryapmri ,[]7 stetiaatcm ugnl carcne and oinhtacrcatri mpal,ymoh aonctuc rfo %80 of scase of nayscdero APH.O cnrmaoaoenAcdi of eht lgnu si hte smto ruqfenet nda lslma lcel coraaicmn si teh eatsl entueqfr ttioshichlagopo eypt fo lgnu narcce dsaceitaos htiw OPHA 7[.]

threo saoeditsac athteiraoxrcc nailceimgnsa icdnuel aarlaegsnyopnh ioaacr,ncm nlrea elcl coacmr,ian gophsaeeaol ercc,na ctsriag rmtuou [,8] earitccnpa cnra,ce rbtaes ehloysldp uoutmr [,9] analm,ome rdthoyi crac,en scmtosraoeao nda teniinslat yolmh.pma

rosiuaV aetrlhuoimocg dootisn,nic dlnciinug RA ,01][ AS ][1,1 paerislotityr nos,doa LSE ]12,[ uyaTaask easiesd 1][,3 ,dscossaroii PAS nda eaeirtnarMedn vfree are nwokn ot be edisataosc whti sith ndticoion as elw.l

yoPlrnmua diisnonoct uchs as tcycis ofri,bssi ,uircobetsusl oiapichtid pylaormun osisibfr ][14 nda glun iltsptartaanonn eahv lsoa eebn steacdaosi whti HOAP.


 +0  (nbme24#8)
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si on one lese ercnocned tuaob hte tfca htat yhreet iggnvi a btae 2 gantois ot a ownam wsoh 82 eewsk ..n..ar...ep?ntg

yobo13  Beta 2 agonists relax the uterus so this would be okay, right? +2
med4fun  inhaled drugs do not have as much of systemic affect and B-agonists are used often in pregnancy for asthma control. SABAS are deemed safe but there are increased birth defects with long acting B-agonists. +

 +1  (nbme24#45)
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orme oifn bauot erBa oetychypLm eSrdnomy he.yghd#m//./oov:oeprcbaeenrtp-tcne-atoyttiih.nilnhsninndryphmr-lyit-oci/smge


 +1  (nbme24#24)
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idbPreneoc makse uoy eeP

nceiilohcC henesclc yuro lbrmucousiet


 +48  (nbme24#30)
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sthi sunqotei eaksm me antw ot ate na e clio kocioe dna epoh i lebde uot

caitlyncloy  pick C and move on was my strategy :P help lol +1
thegooddoctor2  lol good one +1

 +4  (nbme22#36)
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-tirCyCilC enesranipsettd - iant C elcgiroh,ni C atn adnts up 1(a kbo,l)c C tooiarxidc rl(ogpon tq by gmesins w an asce)hlnn

waterloo  that's cool and all but there are so many side affects when it comes to TCAs. H1 antagonism, reduced libido, convulsions. +

 +1  (nbme22#15)
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Cna oemsoen xlipean eth efirfcened enebetw .C aeresle( fo stedor dohtiyr mnrhoeo rmfo a iyhrdot anldg enriailtfdt yb lptmcshoy)ye adn .D el(seRea fo hdiryot nehrmoo omrf a oyhosmtmuapl hirtydo ag.dln

drdoom  @niboonsh, ending a comment with a question mark will make it appear on the "comments seeking answers" lists +4
nwinkelmann  A lymphomatous thyroid gland can either be due to primary thyroid lymphoma (which is almost always NHL, but is very rare) or due to Hashimoto's thyroid progression. Hashimoto's thyroiditis = lymphocytic infiltrate with germinal B cells and Hurthle cells, which upon continued stimulation, can lead to mutation/malignant transformation to B cell lymphoma. These, I believe, would still present with hypothyroidism, and thus would have low T4 and high TSH (opposite of this patient). +1

 +0  (nbme22#20)
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I ma uofoinncs. yhw wlnduto tsih be a socrs veor tusdy?

shokay  there is no washout period and the order of drugs given isn't switched +7

 +0  (nbme22#5)
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My suegs si tath heyt rea ifrnreger to eRrurovtsi )HLVTHI/-V( a lsgnei rdnetdsa svpoieti eness elarin .NRA eRtruovisser are nnkwo ot rcary ersveer triapaenrssct NARnpde-(entde DN.)yoealr-mesAp The htleeapniics si wtha erwht em ffo ucz I ltolumyactaai gohtuht of the amyn tanieevg eness RAN suirevs that ucsae ticealhisnep le(ik rusvnraaie ro yav.surbi)nu pAetlynrap hrete aveh eben a fwe ssecua fo LTHV ignaucs nhe..ita.iseplc eybam tihs is atwh yeht erew gntiyr ot egt ta? kdI tbu i usjt pnste yaw oot hmcu meit on sthi ndam nestouqi sCw:nl8/vr/1p/hiwg.wctlnh/ca/ib.n.scmmip88to5P/.M77te


 +0  (nbme22#19)
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6//bow..t3.ivhwcw/inmn9/ungedtml5hbp9:ps1.15 The ssereohho kieydn saw edectted obrfee yugerrs ni 21 nspetati )%0(8 by hsnauoyro,latgrp gaiopn,rahyg emcudopt atpygmhoro CT() or xcrtryeoe h.uagorypr anoggAyiprh alevedre ulptieml ro omsonlaua lenar eerirtas ni 8 fo 21 patsneti sdduite prlaeepevotiry


 +3  (nbme22#20)
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sihT klin hsa ogdo ctpsieur as efceerern bhiwwnneiissperr-l-y-uselrwtb.ras/oiif:o/.is-epn/eoag/odvpehgttoghslnbsttoteas-gcupirtrll-bru-vm-uoe/geri


 +2  (nbme22#47)
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ihsT is a sace of uacte nattpnasrl trjienoc.e eeskw to htosnm earft hte atpt,nsarln iiteerpnc c8d ronda/ cd4 t cslel ear ateviadct ignasat teh rodno a( epyt 4 RHS) dan the onodr tartss niamgk itniebsoda ainagst eth rnsl.naptta Tsih rteensps sa a cslsvtiiau ihwt ensed natiirltstei hlyyipctcmo larf.isttine 02A8F1( pg 911)

ls3076  Actually was confused about this due to a UW explanation. UW said acute txp rejection has two types - humoral and humoral and cellular. Humoral has Neutrophilic infiltrate + necrotizing vasculitis while cellular has lymphocytosis. Can anyone simplify/explain this please? +3
apurva  We usually look for c4d complement for humoral response in acute graft rejection. Because c4d makes covalent bond with the endothelium can can be found on staining because it is long lasting. +

 -1  (nbme21#34)
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hTe isbuloqe do hte ipotesop taicon of eihtr a.nme fienrrIo luobiqe vseom eht eey PU dna UTO (tetnixr,oo inetlve,oa )AnduciBot. Scine eht nosteuqi asys ttah etrhe si a rarteucf gnnivilov het oarltib forlo, ttah ylmtaautcloai urlse uto D al(imed ucrste dan nofireir ,)bioluqe nvlaige hte olny aclogli ernaws to eb teh nreoifir tsceru dna irfirnoe obelu.iq DhttbKww.WEWt/s.I/pcvlewy/uoa?oI:WcHumh=twk

aishu007  hi, but inferior oblique moves up and in and not out +
d_holles  https://www.youtube.com/watch?v=3J2UZiLVZKA In case ppl need a refresher +

 +5  (nbme21#26)
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i inkth fo htis sa ole femrra joe on shi cnciati afmr kipicng atsakr rarts)o(c aiccin(t or)kesstia

bbr  haha good point +

 +0  (nbme21#32)
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my rntesdnadignu fo hsit is rofm mtoaahp - riltaIseitnt lp(aciaty) ieaoumpnn - saduce by ifesufd anettilsriti l.ttasifirne nCa eb suecad by lmMsyoacap nempu,o RSV, lmyidhaac ,uenopm l,anznefui xloialce urbeniti

athenathefirst  Yeah but how does that help you choose Usual interstital pneumonia? +

 +15  (nbme21#40)
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WIMS

eahps eon - is ti Sa?fe

ahsep 2 - seod ti Wr?ok

aehps 3 - ayn Isne?evmroptm

peahs 4 - tysa on teh Mraekt?

lovebug  Does the drug "SWIM" ? :) FA19, pg256 +

 +3  (nbme21#38)
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i tog tshi nqeuiost hrtgi tub ywh tdnoclu it eb kigon oabbli?

nor16  and why no therapy, i.e. cognitive training` +
jessica_kaushal  first step is to make the patient's environment accomodating for the patient. +2
jessica_kaushal  first step is to make the patient's environment accomodating for the patient. +
tryntofigritout  Because this is a western medicine test. Even though it has shown great protection against AD and memory protection, this test won't allow that. I initially clicked on ginko but thought to myself... na this test doesn't accept an eastern idea. so clicked on the one I know they wanted me to say, and I got it right. ha +5
mumenrider4ever  Wikipedia says "Gingko extract has also been studied in Alzheimer's disease, but there is no good evidence that it has any effect." https://en.wikipedia.org/wiki/Ginkgo_biloba#Traditional_medicine +3

 +10  (nbme21#35)
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htsi aws a umbd qe.sonuit the numeomicn "DDInnoeais esacus rncpeaaIDDi"s is lufsue rhee


 +45  (nbme21#45)
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o/uHww4otmc/Qcy/wttztevhaovsuw2hu=p.?:D.w-b fi ru zyla keli em, iths is a dogo rsherfeer ieovd

d_holles  Amazing video dude. Somehow never learned this in neuro lol. +6
aag  Awesome video! Is this why you can give Mg2+ to eclampsia patients, because if so, mind goddamn blown. +1

 +2  (nbme20#17)
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" Oerth esacssl of neidsoimtac that eaucs aomiapliytcheprren dcnleiu ieetanssdtpsr,an neshyentiaripvte gtnsae, nda dgsur ttah inarcsee leobw yt.omilti areoHepmrnicpliayt asuecd by inmdoticaes si olmonycm ya,omttscipm agsuinc eactahra,orgl nertamlus becadutsrin, and motinp.eec tI si napImortt to eusrne hatt alpcmaiehreoptinyr in an idnIdalviu einattp si eud to ceintmodai and tno to a usrclauttr sleino ni eth y/achhtaylmtpautoiipri ;eraa isth can be lpccmdehsoai by ()1 npsitpog eth nactemiido imyarrtleop ot eeenirtmd hteehrw lncrpoiat vselel ternur to mrlon,a 2)( nhtiiwscg ot a amoictdein ttha dose tno aseuc naecaripeyipthmorl "

t/eonbt..s6pwm4hpwn..9muih:v/2nl8ib50/g/c1wd

nsN-t"enndeddopee-o sdei sfftcee — oghAuthl dooe-swl yraphte emses to eimminzi hte mlcbteoia ocpcosntimlia iddnuce by a edzihtai ro t-edkiieazlhi tedru,cii ti yam ont cnalesreysi nmeiietla reoht seid fesec.tf As na epme,axl sa ymna sa 25 reepctn fo emn treadet iwth 52 gyam/d fo lalhindtorhceo plevedo a ildecen ni xlesua tionnfcu 43].[ eSepl rntasuscdeib can saol cc,uor irapyluclrat fi teh tanpite is on a oudlows-mi diet 3.]4[ wHo ehste obremlps occru is ont owkn."n

omipaewiu8i/5-intape-etn-tdi-tawusa3ernssmsrsh9ntwindotdtyileitt-s.90pst#25.e-acoe2-e/fchn:yn/irpHo-ettruwhecz-i/h0psot


 +4  (nbme20#47)
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vwAmaswh:/FtGbt/whWWtcpewq/=.c1ouotuN0?.kFy niscncelocuhyil alusuly ash v sfta itorduna of aonict zcbu lditzaeembo yb mlspaa uopreect.dsesalonehsi ihWt cptyaali dseht,elarscionepsoue csderdeae stobmelmai of olichieusnycnlc dna utsh eucssa a geldroopn iadotrun fo tioanc fo cihlnonsclycuie t--&-;-g AANEP

chandlerbas  i love that mosquito and then SLAP +




Subcomments ...

submitted by lsmarshall(393),
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el"staPraran heave fl)t(i cocrsu grnudi rthgi alnreictruv pethyrrohyp i..(e legr)eatnenm or yrve raylre eesevr ltef rtlaai ag".lnemetenr RV roteppyyrhh acn eb sene so leysai aeesbuc eth VR is ta het etonrari ecusfra fo eht t.cseh

In sthi pneatit loodb fomr LA to LV sdecrease in iaost,unrta so it is oggni omh.eeewrs orFm het 2O t.as we anc deuced ehret si yblbraop a VDS rc(iansdee VR rrpueses dolwu uacse RVH and tlrransaaep eah)v.e rouFmh,rrte eht itnegtev is keilyl nibsgiedcr tregoytla of talflo seuda(c by npruaeotsoreri pnedmseclait fo the drunbfliinua pu).tmes nI teT e,lplss RV owlfout is oto tdcbeurtso dan tiaentp tges osacinsy dna ;tR&gL inusnhgt tSsaqu ceierans VR,S ieagncrdse ;LgR&t uihg,nsnt ptigtun rome dbool tuohrhg aurnylmpo tirucic dan iilenvger .ascnysio

seagull  i'm pretty sure your a prof and not a student. +15  
nor16  nevertheless, we are greatful for explanation! +  
niboonsh  I remember seeing a question describe parasternal lift in the context of pulm htn. still got this wrong tho fml +  
anotherstudent  Did my question have a typo? It says O2 saturation in the right ventricle is 70, which is equal to the Right atrium and vena cava. It says the O2 saturation in the left ventricle is 82%, which is a decrease from the LA (95) but not equal to the RV, which is why I thought there wasn't a VSD, I assumed there was a weird shunt from the LV to some other part. Will O2 saturation not always equalize? +1  
pseudomonalisa  This is a right to left VSD due to the pulmonic stenosis present in Tetralogy of Fallot. O2 sat will be low (70) in the right ventricle, and from there it'll enter the left ventricle and mix with freshly oxygenated blood coming from the left atrium (95). Because of the mixing, the O2 sat of blood in the left ventricle will be somewhere in the middle of 70 and 95 (82 in this case). You're correct, though, that most other VSDs are left to right and you'd see greater O2 sat in the right ventricle in that case (not sure if it equalizes with the left ventricle though). +  


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naC moeenso elaesp iclfray het s.waenr sI aseecddre nehecrdae esam sa addceeser ogeraitggan? lut;dWno obitnnihii fo het bI/IIIIa rrpoeect ervptne gtangeo?riag

xxabi  I'm not completely sure...but I think its because its aspirin, and aspirin doesn't work on IIb/IIIa receptors. That's why i picked decreased adherence of platelets, figured that was the closest thing to decreased aggregation that still made sense with aspirin's mechanism of action. Hope that helps! +2  
ihavenolife  Aspirin irreversibly inhibits COX which leads to decreased TXA2. TXA2 normally is a vasoconstrictor and induces platelet aggregation, so aspirin inhibits platelet aggregation by downplaying TXA2 not by interacting with IIb/IIIa receptor. (Source FA and UWorld) +20  
fallenistand  In this case, inhibition of COX-1 by aspirin will also reduce the amount of precursors for vascular prostacyclin synthesis, provided, for example, from adhering platelets https://www.ncbi.nlm.nih.gov/pubmed/9263351 +1  
niboonsh  inhibition of IIb/IIIa receptor is the moa of a completely separate class of drugs - Glycoprotein IIb/IIIa (abciximab, eptifabide, tirofiban) +1  
t123  Bad question - TXA2 upregulates GpIIb/IIIa on platelets. So aspirin inhibits their expression. +1  


submitted by neonem(549),
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NTIRs are eth aimn HVI ypatreh gdru atth cna ucesa neob awmror sssoepnriup tno( as omcmno tiwh T.IN)NsR hisT clssa nsdcluie duniievdoz, easdi,nodin tmcitriaenieb, laedmni,viu u,vinesdat rbaaic.av inoudedviZ is otms nokwn rfo tihs ieds efc.eft

enavNliirf = estepoar ttiyciimniroonhzh irab = miygensadcolio o(nt lerayl sude ofr denHVapiiItme)n = thernao imtbcliionaar, moslyt sdeu ofr msteyospncui I mutdhiivnkiaLn e? = etonrah TIRN tub sles kwonn ofr obne mrawro poisensspur

adisdiadochokinetic  Azithromycin is a macrolide, not an aminoglycoside FYI, and its use in HIV is primarily as prophylaxis at very low CD4 counts for, among other things, the mycobacterium avium complex. +7  
nbmehelp  How would we have known to choose Zidovudine over Lamivudine tho +5  
mjmejora  @nbmehelp the sketchy with Princess Izolde (Zidovudine) eating bone marrow was my only tip off +8  
niboonsh  you have ero bone marrow if you take idovudine +1  
niboonsh  the z's were supposed to be bold idk what happened. you have Zero bone marrow if you take Zidovudine +5  
t123  Zidovudine is also a very early NRTI developed. As a good rule of thumb, older drugs have worse side effects +2  
therealslimshady  Zidovudine Zaps your bone marrow (sorry) +1  


submitted by neonem(549),
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ITRNs are teh nmia IHV rahepyt rugd that cna sucae oenb woamrr oniusspsrep (otn sa cmnomo itwh .sNTRIN) Tish cslas cduliens ouidedvniz, dsandeoni,i ,riimcbeiatnet ivmiauen,dl esdtnauvi, racva.bia didviZueon is smto wknon orf tsih side tef.efc

raileNvifn = otpesera ortoinzihiibhaycntrim = dmsiongloaeyic o(nt relyla sued rfo pnni eHeimt)aVId = ornthae tlmionri,iabac tsomly sdue ofr osyiucpmsten I iht inemnvLuka?di = erhonta RNTI btu sesl kwnno fro boen wromar einousprsps

adisdiadochokinetic  Azithromycin is a macrolide, not an aminoglycoside FYI, and its use in HIV is primarily as prophylaxis at very low CD4 counts for, among other things, the mycobacterium avium complex. +7  
nbmehelp  How would we have known to choose Zidovudine over Lamivudine tho +5  
mjmejora  @nbmehelp the sketchy with Princess Izolde (Zidovudine) eating bone marrow was my only tip off +8  
niboonsh  you have ero bone marrow if you take idovudine +1  
niboonsh  the z's were supposed to be bold idk what happened. you have Zero bone marrow if you take Zidovudine +5  
t123  Zidovudine is also a very early NRTI developed. As a good rule of thumb, older drugs have worse side effects +2  
therealslimshady  Zidovudine Zaps your bone marrow (sorry) +1  


submitted by m-ice(321),
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ehT etipant edsne aidclem oitntneta ymeeimatdli, iwhch temsiielan gaiionntb a urtco rd,eor or raiftgrrnnse h.re A unres sedo ton aehv het same gnitiarn and futloaasciinqi as a hi,nipsayc so ti uolwd eb iappparernoit to ksa temh ot emaneix eth it.etapn nAsgki hte itlhsaop lhpicaan iaang udcol eb aaiipp,rpoenrt dna lwudo taek mroe .teim erTo,heref teh sebt pioont ongma ohets iveng is ot kas eth ptantei fi she lliw awllo wthi ehr nhubasd .rsentep

sympathetikey  Garbage question. +54  
masonkingcobra  So two men is better than one apparently +28  
zoggybiscuits  GarBAGE! ? +1  
bigjimbo  gárbágé +4  
fulminant_life  this question is garbage. She doesnt want to be examined by a male how would the presence of her husband make any difference in that respect? +12  
dr.xx  I guess this is a garbage question because what hospital, even small and rural, does not have a female physician on staff. NBME take notice -- this is the 2010s not 1970s. https://images.app.goo.gl/xBL4cK31ta7nG4L39 +9  
medpsychosis  The question here focuses on a specific issue which is the patient's religious conservative beliefs vs. urgency of the situation. A physician is required to respect the patient's autonomy while also balancing between beneficence and non-maleficence. The answer choice where the physician asks the patient if it would be ok to perform the exam with the husband present is an attempt to respect the conservative religious belief of the patient (not being exposed or alone with another man in the absence of her husband) while also allowing the physician to provide necessary medical treatment that could be life saving for her and or the child. Again, this allows for the patient to practice autonomy as she has the right to say no. +15  
sahusema  I showed this question to my parents and they said "this is the kind of stuff you study all day?" smh +25  
sherry  I totally agree this is a garbage question. I personally think there is more garbage question on new NBME forms than the previous ones...they can argue in any way. I feel like they were just trying to make people struggle on bad options when everybody knows what they were trying to ask. +  
niboonsh  This question is a3othobillah +5  
sunshinesweetheart  this question is really not that garbage....actually easy points I was grateful for... yall are just clearly ignorant about Islam. educate yourselves, brethren, just as this exam is trying to get you to do. but yeah I agree there should be an option for female physician lol +5  
drmohandes  I think this NBME24 is a waste of $60. On one hand we have these types of questions, that have 0 connection to our week-month-year-long studying. On the other hand we have "Synaptobrevin" instead of SNARE, because f*ck coming up with good questions. +11  
myoclonictonicbionic  @sunshinesweetheart I actually have studied the religion tremendously and there a clear consensus among all Muslims that in the case of an emergency, it is completely allowed to have someone from the opposite gender examine you. I think this actually represents how ignorant the exam writers are of Islam. +10  
korahelqadam  All it takes is one NBME question concerning muslims for the Islamophobia to jump out I guess +  
sars  This is a very fair question. I agree with sunshinesweetheart above. That is all. +  
wrongcareer69  Garbage question +  
alimd  well we should wait for the question "if a man shouts I CANT BREATHE with a police knee on his neck, what is your next step? Ans- wait 8 minutes." +1  


submitted by neonem(549),
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algFnil on rtsetuhtoecd :hnda hiodspca is msot oonmcm eon to eb ,uetrardfc etlnau is tsom mmcono to eb ddetsaio.cl uanLet lootincasid anc cuase teauc caralp untnel smyrndeo.

iThkn of hte nonimcem "artgtihS iLne To iknP,y erHe sCeom eTh m"Tuhb ofr teh nobse fo teh l,pma rwdgnia a flbaolto ehpsa arsitngt bloew het tmbuh CMP jniot tadajnce to the s,druia nhet iovnmg ot ruyo edmlia i,wrts dna hnet cbak ot het mh.tbu

po,iShcad enu,tal ruetmiq,utr i,msfopir ae,math ataecip,t iz,aedtrpo mzutrepia. Teh lnutea okosl kile sit' eooirptrysl dectadosil .erhe

sympathetikey  Yep. I didn't even look at the X-ray. +9  
dr.xx  loonies love lunate +2  
wes79  she landed on her "right hand", but the X-ray is showing a left hand?? +1  
wes79  i legit have no idea whats going on in that xray lol +9  
nbme4unme  X-ray confused the hell out of me, I was going to put lunate based on Q stem but ended up putting Pisiform because it looks like that's what's messed up in the photo? Should have ignored the picture haha. +1  
nwinkelmann  for @dr.xx, love your mnemonic. I added to it, or at least found an explanation on why it works. "loonies love lunate" and "loonies" are "dislocated" from reality. +3  
niboonsh  Some Lovers Try Positions That They Cant Handle +9  
vsn001  ngl if scaphoid was an option - would've sprung at that real quick -> thanks for teaching me the importance of knowing to look for dislocation vs fracture :D +  
regularstudent  Ahh, the classic "left hand" x-ray but actual fracture of "right hand" NBME tactic +  
sars  I think the x-ray is showing the lunate protruding out of the palmar side. Imagine the situation where you are falling and using your hand to stop the fall. Your lunate will dislocate forward as the rest of the carpal bones recoil back, hence why it protrudes through the palmar side. Thats why it causes an acute carpal tunnel syndrome. +  


submitted by cinnapie(19),
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hyW oesd ryeve EMBN vhea one ro wot cenortei erlteda nqoss??euti

youssefa  Cause we all know what bout to happen to us in this exam :D +33  
niboonsh  lmfaooooooo +  
corgilobacter  erections are a very hard subject +8  


submitted by usmleuser007(370),
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moeS ohtre rndineoce klei llecs adn rdirdeoss for :ercerfnee

  1. tppreSd-leap-na mcirohnat n(ife agarunrl a)yotscmlp in oicnnedEr :tmuosr

  2. ylearlMdu thoyird acroncmai

  3. uicoernnroeedn trno modrccmetooshao ahypmu
  4. iridCcnao uTrmo n(osen)itro --- (osal sha sthees fo mfonriu clsel)
  5. llamS elCl camiaroCn fo usnlg = a,mSll lbue wtlcihse l cnsat samocyltp adn anlrrgau =rcm) nhoait t,lfa vhepdl-aoas cetw silhl cstan lsoacpmyt nad hahrcroyceptmi luenic

  6. lalSm Beul lCsel

  7. iwgEn macoasr tpasaanlci( lnamatnig utmro)
  8. CSC fo gunls
  9. ,tfla eh-dsoaplva swliehlc t acstn tplasocmy nad pirhahtccoryem ilceun
happysingh  i've never heard of " 6. Small Blue Cells" cancer / tumor / carcinoma .... +1  
niboonsh  might want to look at fa pg 665 +  


submitted by roygbiv(20),
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yhW lcdou hits tno eb atcvarualesrx ysoilmsh?e nI FA it assy ctuea mloiychte iotnnsafrus ntreoaci acn be edu to AOB ilicibaptminoty ro auretvslxraca oesimhly.s

niboonsh  because extravascular hemolysis is associated w jaundice. Intravascular hemolysis would have hemoglobinuria but that's not an answer +1  
niboonsh  i mean that is the answer lol +  
krewfoo99  According to pathoma: Intrvascular haemolysis will lead to haemoglobin binding to haptoglobin. This complex will travel to the kidneys and be excreted. This will lead to red colored urine and haemosiduria (Note: This can also lead to acute tubular necrosis) Extravascular haemolysis is when macrophages break down the RBC. Then the Haeme is converted to biliverdin then bilirubin and conjugated in liver, and then excreted. +4  
paperbackwriter  If you look under the "clinical presentation" column of the blood transfusion reactions chart (pg114), it says that hemoglobinuria is with intravascular hemolysis and jaundice is with extravascular. Makes sense because with extravascular hemolysis your splenic macrophages are are chewing up the RBCs and sequestering it in the spleen so you don't get "spillover" -- i.e. clean urine. +1  


submitted by roygbiv(20),
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Wyh cudol hsit tno eb tsarcelarxuav iosyms?ehl nI AF ti ssay tauec hemlyoitc suafnstiorn oercinta nac eb eud to OAB octitiymlbiniap ro rtaxcevurlasa lyoseih.sm

niboonsh  because extravascular hemolysis is associated w jaundice. Intravascular hemolysis would have hemoglobinuria but that's not an answer +1  
niboonsh  i mean that is the answer lol +  
krewfoo99  According to pathoma: Intrvascular haemolysis will lead to haemoglobin binding to haptoglobin. This complex will travel to the kidneys and be excreted. This will lead to red colored urine and haemosiduria (Note: This can also lead to acute tubular necrosis) Extravascular haemolysis is when macrophages break down the RBC. Then the Haeme is converted to biliverdin then bilirubin and conjugated in liver, and then excreted. +4  
paperbackwriter  If you look under the "clinical presentation" column of the blood transfusion reactions chart (pg114), it says that hemoglobinuria is with intravascular hemolysis and jaundice is with extravascular. Makes sense because with extravascular hemolysis your splenic macrophages are are chewing up the RBCs and sequestering it in the spleen so you don't get "spillover" -- i.e. clean urine. +1  


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tI sida ti was ftlaa ot elmsa ni erotu, adn the oteuqsin eksad atbou vile nobr gips.ronff cSnie teh semla eratn’ nigeb nrbo ni teh irfts ,cpael I aids %05 eeafslm adn %0 smle.a

hungrybox  fuck i got baited +30  
jcrll  "live-born offspring" ← baited +21  
sympathetikey  Same :/ +  
arkmoses  smh +  
niboonsh  why is it 50% females tho? +2  
imgdoc  felt like an idiot after i figured out why i got this wrong. +1  
temmy  oh shit! +  
suckitnbme  This isn't exactly right as males can still be born as evidenced by individuals III 6,9,11. This basically an x-linked recessive disease. A carrier mother can still pass her normal X chromosome to a son (50% chance). It's just that the other 50% chance of passing an affected X chromosome results in death of the fetus in utero. Thus all males actually born will not be affected. +2  
makinallkindzofgainz  @suckitnbme, Correct, but if you're a live-born male, you 100% for sure do NOT have the disease, so the chance of a live-born male "being affected" is 0. +3  
spow  @suckitnbme it's not X-linked recessive, otherwise every single son would be affected and therefore have died in utero. It's X-linked dominant +2  
qball  Jail-baited +  


submitted by drdoom(805),
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tacCsaoilnul fro dad. Teh abrypobitil fo eht efatrh bgnei a crierra is 23/ nsice it si wnonk htta he to’esdn evha teh siaese.d Tnhe the irltbaybpio of imh sagsipn ti on ot sih kdi si 2,/1 stuh:

  • aoPibytrlbi of dda enbig rcaerir = /32
  • iPartblobyi fo dad apinssg no sideesa leeall = 2/1

oatlCaulnisc fro omm. Wiht het nryeerdWiHabg- ilen,pPirc uoy nca ifgrue tou hte ilpiaobyrbt of hte othrme ngieb a arreicr:

q = 4r)0/qs00,t1(0 = 0201/

o,S 2pq = 2 * 0/012 * 99002/1, hhcwi is oappxr /1010.

rFo hte ilchd to teg het leella mfor mmo, otw tighsn eedn to hnaepp: )(1 omm tmsu be a crirrea gyt”ozreoe[t]e“h and ()2 mom stmu ssap the eallle to dcihl:

  • iPlbarboiyt of mmo igenb ercrari = 10/01
  • rtobiabyliP of omm ispsgan no iessead aellel = 1/2

tiuPng it lla hetgtoer. N,wo ocmibne lla t:geeroht

= li(ibrptaybo of add iegnb )carerri * aiorlbbiytp( fo dad painssg no iesedsa lelel)a * obiby(ralipt of mmo eignb riea)crr * orlbt(ybiiap fo omm gpnassi no saidese elel)al

= 32/ * /12 * 01/01 * 21/
= 1 ni 006

kernicterusthefrog  To quote Thorgy Thor, drag queen: "ew, Jesus, gross" +35  
niboonsh  This question makes me want to vomit +11  
drdoom  lol +  
5thgencephalosporin  okay wow +  


submitted by aesalmon(81),
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I flee bdum rof gnskia utb nca onemoes eilpaxn ihs?t If sih rsnapet aer fo lecso ot aonrml BMI dan era eerdnncco utbao hsi wthegi hwy uowld hyte eb iaonllgw his rcalieo ptcosnmnoiu to ecdexe ihs ynrege eiduext?eprn ( AKA tngitle hte kid tae oot cumh dan nto rxsceiee )onhgeu

meningitis  That's a modern day mystery. +16  
drdoom  The prompt is only asking "what's the likely cause of obesity?" It's not that they're "allowing" him to eat more than exercise. (Few parents can monitor their kids that closely!) The prompt is only asking what's the most likely explanation for his 95th percentile weight and BMI (given that he otherwise appears normal); in the United States, the most likely explanation is eating way more than you expend. +1  
niboonsh  aka 'merica #firstworldproblems +4  
makinallkindzofgainz  If you are obese, it's because you have consumed calories in excess of your energy expenditure, end of story. (there are factors that affect your energy expenditure, but the simple statement is 100% true, unless you want to argue against the laws of thermodynamics). A is the only correct answer. +1  
tulsigabbard  This answer hit too close to home. +4  
castlblack  I think the reason they point out the average weight of the parents is because leptin disorders are inherited. It helps you eliminate that answer choice. +1  


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nmsoniigeam notcu sa enhnacnig leos?nsi tsh(i emtmnoc eensd to eb rmoe nhat 05 rhtaerascc )nyeprpalt.a

goldenwakosu  I think it’s because meningiomas are able to calcify (aka sometimes they have psamomma bodies). I got this question wrong too but I totally did not completely register that the tumor was in the dura (interhemispheric fissure + central sulcus). Hope that helps! +2  
pipter  the only reason I got this right was because they described the tumour as being near the falx cerebri. +2  
fcambridge  Other hints include being described as round and seen in a female. Both indicative of Meningioma +15  
niboonsh  also meningiomas typically present with seizures or focal neurological signs +  
suckitnbme  I thought enhancing meant it uptakes contrast. Meningiomas are commonly enhancing lesions per Radiopaedia. +  


submitted by johnthurtjr(139),
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I kithn sthi is as godo an aoxetiannpl as I can dfin



submitted by seagull(1404),
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out of ,torsiciyu woh mya loeepp enwk ith?s t(dno eb shy to sya uyo idd ro i)t?ddn

yM rvoypte tnidcouea 'tnidd irignan shit ni .em

johnthurtjr  I did not +1  
nlkrueger  i did not lol +  
ht3  you're definitely not alone lol +  
yotsubato  no idea +  
yotsubato  And its not in FA, so fuck it IMO +1  
niboonsh  i didnt +  
imnotarobotbut  Nope +  
epr94  did not +  
link981  I guessed it because the names sounded similar :D +14  
d_holles  i did not +  
yb_26  I also guessed because both words start with "glu"))) +27  
impostersyndromel1000  same as person above me. also bc arginine carbamoyl phosphate and nag are all related through urea cycle. +1  
jaxx  Not a clue. This was so random. +  
ls3076  no way +  
hyperfukus  no clue +  
mkreamy  this made me feel a lot better. also, no fucking clue +1  
amirmullick3  My immediate thought after reading this was "why would i know this and how does this make me a better doctor?" +7  
mrglass  Generally speaking Glutamine is often used to aminate things. Think brain nitrogen metabolism. You know that F-6-P isn't an amine, and that Glucosamine is, so Glutamine isn't an unrealistic guess. +4  
djtallahassee  yea, I mature 30k anki cards to see this bs +4  
taediggity  I literally shouted wtf in quiet library at this question. +1  
bend_nbme_over  Lol def didn't know it. Looks like I'm not going to be a competent doctor because I don't know the hexosamine pathway lol +21  
drschmoctor  Is it biochemistry? Then I do not know it. +4  
snoochi95  hell no brother +  
roro17  I didn’t +  
bodanese  I did not +  
hatethisshit  nope +  
jesusisking  I Ctrl+F'd glucosamine in FA and it's not even there lol +  
batmane  i definitely guessed, for some reason got it down to arginine and glutamine +1  
waterloo  Nope. +  
monique  I did not +  
issamd1221  didnt +  
baja_blast  Narrowed it down to Arginine and Glutamine figuring the Nitrogen would have to come from one of these two but of course I picked the wrong one. Classic. +1  
amy  +1 no idea! +  
mumenrider4ever  Had no idea what glucosamine was +  
feeeeeever  Ahhh yes the classic Glucosamine from fructose 6-phosphate question....Missed this question harder than the Misoprostol missed swing +1  
surfacegomd  no clue +  
schep  no idea. i could only safely eliminate carbamoyl phosphate because that's urea cycle +  
kernicteruscandycorn  NOPE! +  
chediakhigashi  nurp +  
kidokick  just adding in to say, nope. +  
flvent2120  Lol I didn't either. I think this is just critical thinking though. The amine has to come from somewhere. Glutamine/glutamate is known to transfer amines at the least +1  


submitted by bubbles(66),
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asH yndbyoa dounf a dogo laopexntian rof htsi glotohiys? I unylneeig ahve no aedi hawt m'I nioglok ta.

meningitis  This is common in Klinefelter.. think of the equivalent of Streaked ovaries seen in Turners. White streaks, red/pink material of hyaline, and hyperplasia of Leydig cells. Just remember: It doesn't look like normal structured testicle histology (No organized seminiferous tubules with Sertoli cells around) +10  
niboonsh  https://www.pathologyoutlines.com/topic/testisklinefelter.html these pictures are kinda similar +2  


submitted by bubbles(66),
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rSoyr if Im' bgein .edw.nyh.es esod sith oanwm ehva airrehad edu to t,tnaiss ,tdei nad ece?xreis I d'tdin rayell snntarddeu athw yhet wree gniaks rfo ehre ot be est.nho

.ooo.   I believe they were asking what the most common effect of statins, which is GI upset (including diarrhea). Rarely you can have hepatotoxicity and myopathy but neither of these are a side effect in the answer choices. Hopefully this helps! +1  
niboonsh  Theyre asking about the most common side effect of Orlistat - which is really fatty diarrhea +3  
asharm10  Orlistat is not a statin drug, it basically inhibits pancreatic lipase so that you absorb less fatm drug is used for weight loss. So when you are not absorbing fat you are inviting diarrhea. +2  


submitted by bubbles(66),
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anC soeoemn nlpxiae rrepylpo woh ew nkwo tath sith taitr olslwof nMielnead neisegct dan is atuolsoam rieessevc nda euehofrrmrt how eht sntaerp reew r?ueootyezhsg

I seugdes a otl on tihs tusnoiqe dan otg yulck (:

niboonsh  Autosomal Dominant disorders usually present as defects in structural genes, where as Autosomal Recessive disorders usually present as enzyme deficiencies. P450 is an enzyme, so we are probably dealing with an autosomal recessive disorder. furthermore, the question states there was a "homozygous presence of p450.....". In autosomal recessive problemos, parents are usually heterozygous, meaning that 1/4 of their kiddos will be affected (aka homozygous), 1/2 of the kids will be carriers, and 1/4 of their kids will be unaffected. +36  
nwinkelmann  Is this how we should attack this probelm?: First clue stating endoxifen is active metabolite of Tamoxifen should make us recognize this undering first pass hepatic CYP450 metabolism? Once we know that, the fact that the metabolite is decrease suggests an enzyme defect, which is supported by patient's homozygous enzyme alleles. Then use the general rule that enzyme defects are AR whereas structural protein defects are AD inheritance patters. Once we know the pattern, think that most common transmission of AR comes from two carrier parents. So offspring alleles = 25% homozygous normal, 50% heterozygous carrier, and 25% homozygous affected, thus sister has a 25% of having the same alleles as patient (i.e. homozygous CYP450 2D6*4)? +6  
impostersyndromel1000  we had the exact same thought process, so i too am hoping this is the correct way to approach it get reasoning friend +  
ajss  thanks for this explanation, I totally forgot about AR patterns are most likely enzymes deficiencies, this kind of make the question easier if you approach it that way, thanks +  


submitted by meatus(1),
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'Im syrro tbu htwa am I iinmgss e.h..re I thtuohg teh eolwh npoti fo uetiiscdr si ot ccrtreo ulmevo avledroo yb d?eursisi owH wludo oaltt eovlmu eb aeie?ncrs?d

niboonsh  the question is asking what would happen to the URINARY ph, bicarb, and volume. dont worry, i misread the question too -_- +12  
link981  Also misread the question, thought about the lab volumes of the BLOOD smh +5  
hyperfukus  yooooo me too!!! this is the second NBME i did this on they purposely don't write urine on the arrow categories to mess u up i swear!!! AHHHHHH +2  
medulla  missed this question for the same reason .. still pissed +2  
osler_weber_rendu  I DID NOT READ "URINARY" OH NOOOOOO. Im so dumb. +2  


submitted by k_tron_3000(31),
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eTh snpiicdtero of balirleat lrowe lmbi sosl of vantobiir psimeli DCML ,adameg dna het satnbe TDRs + ebRrgom emse to em ot be imnlgpyi htta eh yslpibos ash atebs oadslisr fmor hslpyiis or( setonhmgi rvey limisra ni aetrn)tsonep.i

sA fro eth thero awnser,s A is nogrw sbecuae sih toomr foutcnni is ttcin,a B si rngwo uaecbse napi and merreapettu detifsic rea nto tnieodne,m C si rongw eesbuca it elmiips a pesciicf eevnr is tdpn,paree but eh sah otsl lerlabtai ionstaens ni hsi rnetei rwelo rittsmeeeix

D si teh s,ictektri nad m’I not 01%0 r,eus btu I dwulo kihtn cduyalrhaptio fo hte reotairn trnl()eva rsoot ldwuo caesu roomt cifsetdi einsc ehyt rarcy omtro nftfees.re uYo igmth lsoa teexcp ttha tormo unfntdsyioc to eb la,tuealirn einsc it oludw be uelynikl ot aveh a mlpbore twhi eth renve rsoto on boht sedis. loas the CDML si nto cealtdo nare hte iaterorn oostr fo the pilsan drc,o so if eth tirearon orsot eewr cfftedea ouy rayell ownult’d xptcee to ese irovtbyra lsos.

So abcllayis prscoes of toilaenimni, I do elef eilk oessrny hateupoyrn is an rlmxyeete uvaeg nerswa hgothu nad I tsnwa’ a naf fo eht .qontiuse

keycompany  This is a great rationale. I would like to add on that D is wrong because Radicular Neuropathy of the anterior lumbar roots would (1) be painful [radicular neuropathy is characterized by radiating pain (hence the word “Radicular”); this patient has numbness and tingling, not pain] and (2) because the anterior lumbar roots are the motor roots and do not carry sensory innervation. This patient is having a problem with his dorsal spinal cord (not anterior/ventral). +30  
hello  Want to clarify that "radiculopathy" is not synonymous with pain. Radiculopathy can cause pain, weakness, or numbness. I think the only reason Choice D. was incorrect because it discussed the "anterior lumbar roots", which would affect motor function. +15  
niboonsh  Radiculopathy is damage to the actual nerve itself, wouldnt that make it a LMN lesion and babinski would be negative? +1  
link981  Great explanation guys +  
usmel2020  UW QID: 12035 explains what you are testing with Romberg sign +5  
jurrutia  "Radiculo-pathy" comes from latin terms meaning "root-disease". +  


submitted by sirminalot(-82),
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aecli[ps]

niboonsh  this is disgusting. +10  


submitted by haliburton(208),
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link ot ortanoc amgirad

yotsubato  How is that NOT posterior to middle concha? bad question +10  
sympathetikey  @yotsubato - That would have been if it was the spehnoid sinus (I got it wrong too btw) +2  
niboonsh  this is a good video if u need a visual https://www.youtube.com/watch?v=mf7rY1VNy70 +3  
sahusema  Sphenoethmoidal RECESS not sphenoethmoidal SINUS +3  


submitted by whossayin(20),
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the qiueostn swa yrev rloyop eowrdd in ym onni,iop aoybnyd seel agre?e

niboonsh  yea it was a dumbass question, whoever is writing these questions is undoubtedly a crazy genius but homeboy (or homegirl...homeperson?) needs a few grammar lessons. +4  
yex  I agree. We know that it is a teratogen, but how does that question directs you to think about teratogenic effects instead of something physiologic? +5  
dr_jan_itor  The questions in the NBMEs by default are reject questions. So highly selective to be awful questsions. I am recieving regular heads up that the stems on the real thing lately are like 10-12 lines long. So these questions are not anywhere near like the test. NBME has f'd us good for this particular round of practice forms. +  


submitted by tissue creep(103),
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dtAhrpoor orf ures, btu fro the rocred mI' reptyt sure this saw Cyniuaugnhk sir.uV ylnO ogt sthi ofrm a dlWorU eintusoq sa I nat'hd eesn ti unlti ,ethn tbu paerylantp teh lritaaargh is yreall d,ab iwhhc is htwa rdwe me to hte ens.rwa

duntcuxo/v/d:k.ii//tg.ehcamnhtn.csypghwwlw

meningitis  More like Zika Virus (Same a. aegypti vector) since it says she has rash associated to her bone and muscle pain. I had Zika one time (i live in Puerto Rico). Remember also dengue and Zika are Flavivirus. Dengue can cause hemolysis (hemorrhagic), and Zika is associated with Guillen Barre and fetal abnormalities. +12  
nala_ula  I'm shocked that I found a fellow puerto rican on this site! Good luck on your test! +1  
namira  dont be shocked! me too! exito! +2  
niboonsh  Dengue is also known as "bone break fever" which makes me think its more likely to be dengue due to the "excruciating pains in joints and muscles". https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242787/ +20  
dr_jan_itor  I was thinking that its Murine typhus transmitted by fleas +  
monique  I would say this is more likely scenario of either Dengue or Chikungunya, not Zika virus. Excruciating pain is common in those, not in Zika. Zika has milder symptoms of those three infection. +2  
jakeperalta  Can confirm that Chikungunya's arthralgia is pretty horrible, from personal experience. +  
almondbreeze  UW: co-infection with chikungunya virus with dengue virus can occure bc Aedes mosquito is a vector of both Chiungunya, dengue, and zika +  
lovebug  FA2019, page 167 RNA virusesy. +  
lovebug  Found that Chikungunya also have Rash./// An erythematous macular or maculopapular rash usually appears in the first 2–3 days of the illness and subsides within 7–10 days. It can be patchy or diffuse on the face, trunk and limbs. It is typically asymptomatic but may be pruritic (Taubitz W, Cramer JP, Kapaun A, et al. Chikungunya fever in travelers: clinical presentation and course. Clin Infect Dis. 2007; 45: e1. ) +1  


submitted by drdoom(805),
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5,200 dstnsuet ... but ouy ndfi out gudirn yuro nliaiit rscnee that 005 dalraye aevh het asseeid. oS, rsuoktite hoest .loeppe tTah vleesa ,0020 nutdsets who todn’ veah hte asseied.

revO teh seuorc fo 1 y,ear uoy cedvoisr 200 ttedssnu edvodeple het fnnc.tioei h:sTu

200 nwe aescs / 2,000 epeopl hwo n’itdd haev teh edaiess ehwn uoy sdteatr oyur dstyu = 10 cnreept

iy,rTck cyirtk EMBN ...

sympathetikey  Ah, I see. Thank you! +  
niboonsh  Im mad at how simple this question actually is +7  
sahusema  Incidence is measured from those AT RISK. People with the disease are not considered to be at risk. So 2500 - 500 = 2000 people at-risk. Of those 2000, within one year 200 develop the disease. So 200/2000 of the at-risk population develop the disease. 20/2000 = 10% = incidence +3  
daddyusmle  fuck im retarded +2  


submitted by nosancuck(85),
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oY sdi B ogt ON RNEINTLA MFEELA ASORNG

hWy ?a!?td?

We eb ilokon at onosmee htwi an SRY mfro eerd Y moeDi yh!cer eb a Y erhiocm Homie so hyet eb imnak eosm iseTst imnreDetin aotrFc iwhch I be rues esmka oems inec ill NTIA RMALNLEUI OCFATR so dye tina got htat eeFaml nelrnatI rcTat u knwo htwa i eb ysina

nAd nceis iwmmzni is ad EALUFDT ethy slti be tgntei sedo uysps lips dna raessteb

meningitis  The above explanation is correct (disregarding the hard to read and unprofessional dialect) but just in case anyone was wondering: chromatin-negative= Just a quick way of knowing it was a boy. The term applies to the nuclei of cells in normal males as well as those in individuals with certain chromosomal abnormalities +16  
yotsubato  Turner syndrome patients are also chromatin negative as well though.... +5  
sympathetikey  I didn't know a complication post-meningitis was lack of humor. +5  
sympathetikey  Ah, didn't read the last line. Yeah, that is taking it a bit far +20  
niboonsh  yall are haters. this is the first explanation that has ever made sense to me +5  
arkmoses  https://www.youtube.com/watch?v=yuXL-3eoB-o&t=77s Interesting syndrome watching this helped me to put it into real life perspective, interesting points they have no pubic hair/body hair, they apparently also dont smell, and breast size is usually increased... +1  
whoissaad  How does chormatin-negative indicate a normal cell? Isn't chormatin just condensed DNA? +1  
cienfuegos  According to this paper most individuals with Turner Syndrome are chromatin negative: "One of the initial laboratory procedures used to confirm or rule out this diagnosis involves a sex chromatin determination from a buccal smear. Cells from the lining of the mouth are stained for the presence or absence of X-chromatin or Barr bodies, which represent a portion of an inactivated X chromosome. The typical Turner’s syndrome patient, who has 45 chromosomes and only one sex chromosome (an X), has no Barr bodies and is, therefore, X-chromatin negative. This abnormal X-chromatin negative finding in the majority of Turner’s syndrome females is similar to the result found in a normal male, who also has only one X chromosome, and differs from the X-chromatin positive condition observed in the normal female, who has two X chromosomes. Occasionally, the patient with features of Turner’s syndrome is found to be X-chromatin positive." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233891/ +1  
hyperfukus  i really hate haters this is awesome! +1  
selectuw  to add to the above, free testosterone is aromatized to estrogen leading to breast development +  
misrao  Is the free testosterone not creating male internal or external gentalia because of the defect in androgen receptors? +  


submitted by mcl(578),
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Pre 608p in FA 09,21 SRY no Y oomeosmhrc lsetrsu ni toledmpneev fo esst.te HTD tsslrue ni needtlompve fo meal lrantexe iieantgal dna( the se)totrp.a

mrsmac  No sertoli cells or lack of mullerian inhibitory factor makes more sense. bc there is both male and female internal genitalia but only male external genatalia. and karyotype would show 46XY. First Aid 2018 pg. 604 - the "Sexual Differentiation" charge delineates exactly this. If it were 5areductase deficiency the child would have testicles and scrotum, which in this case is absence. Hope this makes sense. Please let me know if you disagree and why. Thanks. +  
mixmasta  I believe the tricky part is that they don't mention the status of the Male external genitalia. Pg. 605 from FA ( bottom portion) shows the external development of the Male/Female genitalia; you see DHT is need for male. Furthermore, pg. 604 (SEXUAL DIFFERENTIATION) DHT is also needed for Male external development. +  
niboonsh  My understanding of this is that the diagnosis is 5alpha reductase deficiency because the newborn has female external (aka ambiguous) with male internal (aka "male genital ducts"). According to FA, leydig cells produce testosterone, which can either stimulate the mesonephric duct to form the INTERNAL male genitals (as see in the pt). Testosterone can also be acted on by 5alpha reductase to become Dihydrotestosterone, which forms the male EXTERNAL genitalia. Since this kid has "female" genitals, but has male insides and is 46XY, id say this is a simple case of 5alpha reductase deficiency. No sertoli cells or no MIF would present as both female and male internal (because MIF typically inhibits differentiation of female internal) and male external genitalia (bcuz leydig cells are unaffected) +15  


submitted by uslme123(57),
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vrey sitpdu .uiqsenot hTe svriu aws nhdilae -- stba ngha piuesd enhw ehty slpee nda rolod. oS ti essrdap to het rniab eltiydcr omfr the crftoalyo mysste iva rgreedaotr rstoaprtn htuorgh .serenv

niboonsh  yea, aeresol transmission via bat poop in caves +  
len49  How do you know the virus was inhaled? Doesn't mention it. Moreover, non-bite/scratch transmission is extremely rare. +  
makinallkindzofgainz  You get rabies by being bitten, not by inhaling it +  
drzed  She was probably bitten by a bat; many times the bite is not recognized ('unapparent bites'), and thus the CDC recommends that even if you think you have been bitten by a bat (or that you COULD have been bitten), you should go and get active/passive immunization immediately. +  
mangotango  Sketchy (and Zanki) says you can get rabies via animal bites OR aerosol transmission. In the U.S. it's most commonly through bats. It could also be through skunks (Western U.S.) or foxes/raccoons (Eastern U.S.). I remember this by thinking about how skunks smell so bad! +  


submitted by mcl(578),
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eiionenMht si na eelnstsai nomai dci.a llA hrseto steldi are nt.o

scalpelofthenorth  Pg 81 Tyrosine is listed as an essential AA. Should be tryptophan for those who got this wrong like me. +  
neonem  But tyrosine can come from phenylalanine, so it's not really essential right? +  
gh889  in FA2019, it is listed as Tryptophan, not Tyrosine. That was corrected. +15  
usmleuser007  Note: Tyrosine is ONLY essential with PKU in children +  
niboonsh  bro FA2018 lists tyrosine as an essential AA. They played us. +1  


submitted by calcium196(11),
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dtm-bdiaeiuniUqeti ysooispelrt is ont vrrsbeiley tafecedf by iunlnsi. Teh osetuniq skas fro erbvlriees wsya htta niuisnl affcest ,it dna iitnouibitnqua olduw edal to antaoredgdi iav os,raetsep hicwh si ont erieesr.bvl yel/Nccslcaturaiomp gntusihn mksae essne esaceub FXOO si a nntiprtcoisar ,aortfc so it ’atcn od tsi jbo if ti is ni teh tlsyam!ocp

meningitis  Thank you for your explanation! One question: How about the serine phosphorylation? Is it answered by pure memorization that the FOXO TF is serine phosphorylated, or is it a general fact that all TF's are serine-threonine phosphorylated? +  
tsl19  I'm not sure, but it may be as simple as this: ubiquitin-mediated proteolysis is irreversible, but both N/C shuttling and phosphorylation are generally reversible processes. +  
didelphus  I also guessed that FOXO must be a part of the PI3K pathway, since insulin regulates metabolism through PI3K and the question stem specifically mentions that. Phosphorylation is a major part of that pathway, so even indirectly phosphorylation would regulate FOXO. Frustrating question. +17  
niboonsh  yes, FOXO is affected downstream of the activation of PI3K. This is a really good video that explains the whole cascade https://www.youtube.com/watch?v=ewgLd9N3s-4 +2  
alexb  According to wikipedia (https://en.wikipedia.org/wiki/FOXO1) phosphorylation of FOXO1 is irreversible. This is referring to phosphorylation of serine residues on FOXO by Akt, which occurs in response to insulin. But the NBME answer suggests it's reversible. What's up? +1  
almondbreeze  could wiki be wrong on phosphorylation being irreversible? according to this article, it is a reversible process: regulation of FoxO transcription factors by reversible phosphorylation and acetylation (https://www.sciencedirect.com/science/article/pii/S0167488911000735#s0010) some wiki info, however, is helpful : In its un-phosphorylated state, FOXO1 is localized to the nucleus, where it binds to the insulin response sequence located in the promoter for glucose 6-phosphatase and increases its rate of transcription. FOXO1, through increasing transcription of glucose-6-phosphatase, indirectly increases the rate of hepatic glucose production.[19] However, when FOXO1 is phosphorylated by Akt on Thr-24, Ser-256, and Ser-319, it is excluded from the nucleus, where it is then ubiquitinated and degraded. The phosphorylation of FOXO1 by Akt subsequently decreases the hepatic glucose production through a decrease in transcription of glucose 6-phosphatase. +  
leaf_house  It seems like the phosphorylation from Akt leads to destruction, but maybe the assumption is that that phosphorylation step (excluding every other step of ubiquitin-proteosome pathway) is reversible, where proteolysis is final. @niboonsh video is good but doesn't split this one. +  


submitted by usmleuser007(370),
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aCn ooesemn apesel xaenlpi hyw 'cant claohlo eb retrocc in hsit tt?sgnei

niboonsh  rhinorrhea is specific to withdrawal from opioids (aka heroin). Look at page 554 in FA2018 +11  
dr_jan_itor  what if the alcoholic just has a concurrent rhinovirus infection ;) +5  
lovebug  and FA2019 page 538. +  


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neaitlizod eerprefdr eud ot slenig osde

sweetmed  or metronidazole +  
niboonsh  what would his diagnosis be tho? +  
lostweightthxnorovirus  @niboonsh Giardia I believe. the trophozoite is pictured in the problem and has a classic "shield-like" appearance. FA 2019 pg. 155 has more information and the sketchy for it was really good! +1  
nwinkelmann  Per FA, DOC for giardia = metronidazole. MOA of metronidazole = formation of toxic free radical metabolites in the bacterial cell wall that damage DNA making it bactericidal and antiprotozoal. Metro treats = GET GAP = giardia, entamoeba, trichomonas, Gardnerella, anaerobes (below diaphragm), and H. pylori (as an alternative to amoxicillin in PCN allergy). Adverse effects = disulfiram-like reaction, HA, and metallic taste. I didn't know what Tinidazole is, and found out it is of the same drug class as Metronidazole, so makes sense why it would also be used for Giardia. For the purpose of the UMSLE 1, though, I think metronidazole would be DOC (especially because tinidazole isn't in FA). +8  
mannywillsee  This little bug has has a face, and now you can't unsee it either! +  


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ytiudhero skic demyorsn is temssoiem ldacel l"wo T3 son."dyrme Aslo yuo onwk ttah eth naettpi si dhiyroeut seubcae rhe T4 dna HTS rae wihtni eht neefcrree arn.ge heS si ic.ks

yotsubato  This is not in FA btw. +9  
niboonsh  https://www.ncbi.nlm.nih.gov/books/NBK482219/ probably caused by her recurrent pneumonia +3  
eacv  I though in this one as a sick sinus syndrome hahaha in UW. +  
pg32  Pretty sure boards and beyond teaches this wrong. Dr. Ryan says that in euthyroid sick syndrome T3, T4 and TSH will be low, but rT3 will be elevated. +  
pathogen7  In reality, TSH and T4 levels can be highly variable based on the stage of Euthyroid sick syndrome. One thing that happens for sure, I believe, is that T3 is down and rT3 is up. +1  


submitted by taway(29),
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Jstu sa a teno for daynyob lese hwo aws FWT at owh /3/030392)(0)2( = .1.5.a1/ otl of usneoiqt nasbk dnuro /3902 ro( any slailrymi arelg cotaf)nir uot ot 1

gh889  I think you meant 2(29/30)(1/30) just to clarify! +7  
niboonsh  i am confusion +2  
arkmoses  You have to use the hardy weinberg formula (1=p^2+2qp+q^2)and p + q = 1 they basically tell you that q^2=1/900 which makes q=1/30 now you can figure out (p=1-q) so p=1-(1/30), p=29/30 then to figure out carrier you solve for 2qp, 2(29/30)(1/30)=1/15 I got it wrong cuz I forgot how to figure out p but hopefully wont happen on the real deal. +5  
garibay92  2pq= 2(29/30)(1/30).... Transform this to 2 1 1 2 1 x x = _ = ____ 1 1 30 30 15 +  
garibay92  Nevermind :/ It didn't come out as planned :( +  
garibay92  /Users/carlosgutierrez/Desktop/IMG_2423.jpg +  
pg32  How do we know this disease is autosomal recessive? I assumed it was just because they love these carrier frequency questions with AR diseases, but how do we know it's AR? +  
turtlepenlight  Sounds like Gaucher (ish?) if i'm remembering correctly +5  


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In ceohcsnpgiy asilppydio, usmre uisdom is wo,l nad arfet wtera epontrviida et,st neriu ayslotlmio is n neUe.acdeirsir tlomoialsy sdoe otn srianece iwht pssoivreasn ijtnocein

In rcegoinnehp stbeedai piius,sind eumrs moiusd si hghi adn rhtee is no lamihdec/ng rcisneae in ineru tiloylmsao refta treaw aovdipnetir

yotsubato  This patient does not undergo a water deprivation test +12  
niboonsh  Compulsive water drinking or psychogenic polydipsia is now increasingly seen in psychiatric populations. Effects of increased water intake can lead to hyponatremia causing symptoms of nausea, vomiting, seizures, delirium and can even be life threatening if not recognized and managed early. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579464/ +7  
missi19998  Just wondering why it in not resistance to ADH action of vasopressin +  
amarousis  because he would be hypernatremic with no ADH. can't resorb any water +1  
minhphuongpnt07  low osm/urine, low os/plasma => psychogenic polydipsia +  
benitezmena  In this question the pt had a normal urine osm (80) a low urine osm would be <50mosmol/kg. +  
euchromatin69  u world 212 +